Data are subject to change due to the rapidly evolving situation 1

Coronavirus Disease 2019 (COVID-19)

National Surveillance Report as of 12/05/2020

Date of publication: 14/05/2020

Produced by the Epidemiological Surveillance Unit of the Ministry of Health Contributors: Annalisa Quattrocchi, Ioannis Mamais, Valentinos Silvestros, Anna Demetriou (Health Monitoring Unit), Maria Athanasiadou (Health Monitoring Unit), Theopisti Kyprianou (Health Monitoring Unit), Androulla Stylianou, Sotiroula Sotiriou, Fani Theofhanous, Christos Charalambous, Ioanna Gregoriou, Maria Koliou, Georgios Nikolopoulos and Elisavet Constantinou

Scientific Committee: Elisavet Constantinou, Constantinos Constantinou, Niki Paphitou, Georgios Nikolopoulos, Maria Koliou, George Panos, Eirini Christaki, Zoi – Dorothea Pana, Constantinos Tsioutis, Leondios Kostrikis, Peter Karayiannis, George Petrikkos, Petros Agathangelou, George Mixides

Suggested citation: Epidemiological Surveillance Unit of the Ministry of Health, Cyprus. National Situation Report. Coronavirus Disease 2019 (COVID-19), 14 May 2020.

Data are subject to change due to the rapidly evolving situation 2

Summary

As of May 12th, a total of 904 COVID-19 cases and 23 deaths (case fatality rate: 2.5%) have been reported in the Republic of Cyprus.

Among these cases, 20.9% are health-care workers (n = 189) - 4.3% physicians (n = 39), 10.5% nurses (n = 95), 1.4% other health occupations (n = 13), and 4.7% auxiliary staff (n = 42).

The median age of cases is 45 years (interquartile range - IQR: 32-59 years); 49.8% are female and 50.2% are male.

Overall, of 760 cases for which the place of exposure was known, locally acquired infections (index cases and close-contacts of confirmed cases) were 631 (83%) - of these 8.2% (n = 62) were related to a health-care facility (General Hospital in Pafos) and 12.7% (n = 80) were reported in Aradippou municipality.

In total, 19.1% (n = 173) of cases received hospital care, of which 135 (78%) have been discharged alive from the hospital. Median age of all hospitalized patients is: 62 years (interquartile range: 49-73 years), and 65.3% are males.

Four patients were still in intensive care units (for part of the day if they died, were discharged or transferred on that day or for the whole day, by May 12th); all of these were intubated.

Overall, 481 (53.2%) cases have recovered.

A total of 78,239 tests have been performed as of May 12th (8,932.4 per 100,000 population).

Data are subject to change due to the rapidly evolving situation 3

Epidemiological surveillance in the Republic of Cyprus

Analyses are based on laboratory-confirmed cases notified to the Epidemiological Surveillance Unit of the Ministry of Health.

As of May 12th, 904 laboratory-confirmed cases of coronavirus disease 2019 (COVID-19) have been reported (Figure 1 and 2).

The median time between symptoms onset and date of sampling was 4 days (Interquartile range - IQR: 2-7 days). It should be noted that for 14 cases the date of sample collection was before the onset of symptoms because of immediate testing of contacts of possible and laboratory-confirmed cases.

As of May 12th, the 14-day cumulative incidence rate of COVID-19 (per 100,000 population), a measure which reflects the number of active COVID-19 cases in the population (prevalence)1, is 7 per 100,000 population (Figure 3).

Figure 1: Number of laboratory-confirmed COVID-19-cases in Cyprus since 01/03/2020 by date of sample collection and date of symptoms onset (n = 904 and n = 477 with data available, respectively). Recent data should be interpreted with caution due to the possibility that cases with date of onset within the reporting period have not yet been diagnosed.

1Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK –

seventh update, 25 March 2020. Stockholm: ECDC; 2020.

https://www.ecdc.europa.eu/sites/default/files/documents/RRA-seventh-update-Outbreak-of-

coronavirus-disease-COVID-19.pdf

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Data are subject to change due to the rapidly evolving situation 4

Figure 2: Number and cumulative number of laboratory-confirmed COVID-19-cases in Cyprus since 01/03/2020, by date of laboratory reporting (n = 904). Recent data should be interpreted with caution due to the possibility that cases with date of onset within the reporting period have not yet been diagnosed.

Figure 3. COVID-19 14-day cumulative incidence rate per 100,000 population (proxy of COVID-19 prevalence). March 23rd represents the first 14th day since cases have been reported.

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Data are subject to change due to the rapidly evolving situation 5

Characteristics of the cases Among these cases, 50.2% are male (n = 454) and 49.8% female (n = 450). The median age of cases is 45 years (IQR: 32-59 years). By age groups, cases included 56 infants, children and adolescents aged 0-17 years-old (6.2%), 625 adults aged 18-59 years (69.1%), and 223 persons aged 60 years and older (24.7%) (Figure 4).

Figure 4: Laboratory-confirmed COVID-19-cases in Cyprus by sex and age groups.

Among all cases, 350 (38.7%) were reported in Nicosia district, 234 (25.9%) in Larnaka, 155 (17.2%) in Pafos, 103 (11.4%) in Limassol, 41 (4.5%) in Ammochostos, and 21 (2.3%) were reported either in British bases or had a residence abroad, or information was not available (Table A1 in appendix). Figure A1 in appendix shows the distribution of cases by postal code. Notably, 123 cases (13.6%) were reported in Aradippou, a municipality in Larnaka district (Table A1 in appendix). Cases in Aradippou, including a cluster in a local bakery production line, are mainly males (58.5%; n = 72) and the median age is 49 years (IQR: 33-62 years). If the cluster is excluded, cases are mainly female (53.7%; n = 51) and the median age is 55 years (IQR: 39-69years).

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Data are subject to change due to the rapidly evolving situation 6

Among the 904 cases, 20.9% are health-care workers2 (n = 189) - 4.3% physicians (n = 39), 10.5% nurses (n = 95), 1.4% other health occupations (n = 13), and 4.7% auxiliary staff (n = 42). Table 1 shows the distribution of health-care workers by district of residence. Table 1: Health-care workers by district of residence (n=189).

District Health-care

worker Physicians Nurses

Other health

occupations

Auxiliary staff

Ammochostos 16 3 7 1 5

Larnaka 43 7 24 3 9

Limassol 16 3 9 2 2

Nicosia 55 12 23 5 15

Pafos 59 14 32 2 11

Total 189 39 95 13 42

Epidemiological link As of May 12th, place of exposure is available for 760 cases (84.1%). In total, 17% (n = 129) of laboratory-confirmed COVID-19-cases had history of travel or residence abroad during the 14 days prior to symptom onset (imported). These cases have a direct link to the UK and Greece, mainly. Locally acquired infections (index cases and close-contacts of confirmed cases) occurred in 83% (n = 631 of 760 with known place of exposure) of the cases, of which 8.2% (n = 62) were related to a health-care facility (General Hospital in Pafos). Of all cases in Aradippou (Larnaka district) (n = 123), 80 (65%) were locally-acquired, 10 (8.1%) imported and for 33 cases (26.8%) the epidemiological link was not recorded at the moment. Table A1 in the appendix shows the number and the rate (per 100,000 population) of locally-acquired cases by district of residence.

2 The term “health-care worker” is based on the occupation and not on the place of exposure. Health-

care workers are defined as all health care professionals, allied health workers, and auxiliary health

workers.

Data are subject to change due to the rapidly evolving situation 7

Clinical features Of the 904 laboratory-confirmed COVID-19-cases, clinical information is available for 98.5% (n = 890), of which 31.1% (n = 269) reported no symptoms at diagnosis and 67.5% (n = 610) reported at least one symptom. The most commonly reported symptoms were:

cough (308/879; 35%),

fever (284/878; 32.3%),

myalgia (199/877; 22.7%),

sore throat (156/875; 17.8%),

anosmia (107/787; 13.6%), and

shortness of breath (105/862; 12.2%). Other reported symptoms were diarrhoea, runny nose, and headache. Table A2 in appendix reports the sex and age distribution of asymptomatic cases at diagnosis.

Pre-existing conditions Information on comorbidities was available for 795 (87.9%) cases. Of these, 325 (40.8%) reported at least one comorbidity. The most commonly reported comorbidities were:

hypertension (126/788; 16%),

diabetes (72/769; 9.4%),

heart disease (62/790; 7.8%), and

cancer (24/795; 3%). Other reported comorbidities were chronic kidney disease, autoimmune disease, and chronic respiratory disease.

Data are subject to change due to the rapidly evolving situation 8

Deaths As of May 12th, 23 deaths were reported in Cyprus (Case Fatality Rate - CFR: 2.5%). The mortality rate for COVID-19 is 2.6 per 100,000 population. Seventeen deaths (73.9%) occurred in men and six (26.1%) in women; the median age of all deaths was 76 years (IQR: 66-79 years). Nine deaths were reported among residents in Larnaka, six in Pafos, three in Nicosia and Ammochostos, each, and two in Limassol (Appendix Table A3). The median time from date of sampling to death was 8 days (IQR: 4-18 days). Figure A3 shows the Kaplan-Meier curve of the time from date of sampling to death. For 16 deaths, COVID-19 was the underlying cause of death (COVID-19 CFR: 1.8%). Figure 5 reports the number of deaths by date.

Figure 5: Number of deaths among COVID-19 cases in Cyprus by date of death (n = 23).

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Hospitalization and intensive care unit (ICU) admissions3 In total, 19.1% (n = 173) of people with COVID-19 received hospital care, and 135 patients (78%) have been discharged alive from the hospital. The median age of hospitalized patients was 62 years (IQR: 49-73 years). Hospitalized cases were mainly males (n = 113; 65.3%). Figure 6 shows the total number of hospital admissions by date.

Figure 6: Number of laboratory-confirmed COVID-19 cases by date of hospital admission (n = 173). * Date of hospital admission; for inpatients hospitalised prior to the beginning of the epidemic, it was replaced with date of sampling.

Overall, 32 cases (18.5% of all hospitalized patients) have been admitted to ICU4, of which 4 were still in ICU (as of May 12th). A total of 27 ICU patients (84.4% of all ICU patients) have been intubated, of which 4 (100% of all patients currently in ICU) are still intubated. The overall median length of stay in ICU (for all 32 ICU cases, considering those still in ICU until May 12th) was 11 days (IQR: 8-27.5 days). Figure A4 shows the Kaplan-Meier curve of the length of stay in ICU.

3 Data on hospitalisation and ICU are provisional and should be interpreted with caution because delay

in data reporting is likely; for the construction of the curve, people are no longer in an ICU the day next

to the date of their discharge, death or transfer. 4 Intensive care unit (ICU) refers only to the ICU in Limassol General Hospital and to the ICU in Nicosia

General Hospital.

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Data are subject to change due to the rapidly evolving situation 10

For patients who died while in ICU (n = 15), the median length of stay in ICU was 10 days (IQR: 3-20). Figure A5 shows the Kaplan-Meier curve of the length of stay in ICU for the people who died. For patients transferred/discharged alive from ICU (n = 13), the median length of stay in ICU was 10 days (IQR: 8-27 days). The median age of patients ever admitted to ICU was 65.5 years (IQR: 56-75 years). ICU patients are mainly male (n = 23; 71.9%). The number of cases currently in ICU is 0.5 per 100,000 population. For comparison, Italy and Lombardia reported the highest rates of 6.7 per 100,000 population (n = 4,068) and 13.8 per 100,000 population (n = 1,381) on April 3rd. The ICU rates in Italy and Lombardia on May 12th are 1.6 per 100,000 population (n = 952) and 3.2 per 100,000 population (n = 322) (https://github.com/pcm-dpc/COVID-19/blob/master/dati-andamento-nazionale/dpc-covid19-ita-andamento-nazionale-20200512.csv; https://github.com/pcm-dpc/COVID-19/blob/master/dati-regioni/dpc-covid19-ita-regioni-20200512.csv). Figure 7 shows the number of patients in ICU, by day and intubation. Table A4 in the appendix shows the total number of ICU admissions by date.

Figure 7: Number of laboratory-confirmed COVID-19 cases in ICU by date and intubation. *Date of discharge/transfer/death included

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Data are subject to change due to the rapidly evolving situation 11

Recovered As of May 12th, 53.2% (n = 481) of COVID-19 cases have recovered5. The median time between the second negative result and the first date of sampling was 21 days (IQR: 18-28 days). Table 2 shows the number and percentage of recovered cases and their characteristics. Table 2: Characteristics of recovered cases (n = 481).

Characteristics Total Recovered

N n %

Total 904 481 53.3 Sex

Male 454 227 50.0 Female 450 254 56.4

Age groups (years)

0-9 29 11 37.9 10-19 37 18 48.6 20-29 117 64 54.7 30-39 179 105 58.7 40-49 157 77 49.0 50-59 162 92 56.8 60-69 112 59 52.7 70-79 84 43 51.2 80+ 27 12 44.4

Median age in years (IQR*)

45 (32-59) 45 (32-59)

5 For symptomatic cases, or for cases hospitalised, a COVID-19 case can be considered cured after the

resolution of symptoms and two negative tests for SARS-CoV-2 at 24-hour interval at least.

For asymptomatic cases, or for persons isolated at home, the negative tests to document virus clearance

should be obtained at a minimum of 14 days after the initial positive test (end of the quarantine period).

Novel coronavirus (SARS-CoV-2). Discharge criteria for confirmed COVID-19 cases- When is it safe to

discharge COVID-19 cases from the hospital or end home isolation? - Technical Report, 10 March 2020.

Stockholm: ECDC; 2020.

Data are subject to change due to the rapidly evolving situation 12

Comparison with selected countries As of May 12th, in Cyprus the reporting rate was 103.2 cases per 100,000 population, the mortality rate was 2.6 deaths per 100,000 population and the CFR was 2.5%. Table 3 shows COVID-19 indicators for Cyprus and other selected countries. Figure A2 in appendix reports the rates of cumulative tests and cases (per 100,000 population) in Cyprus and other selected countries. In Cyprus the testing rate is 8,932.4 per 100,000 population. It should be noted that the number of cases, tests and deaths for Cyprus are aggregated and include people from abroad and the British bases, while the total population does not include inhabitants from abroad or from the British bases.

Table 3: COVID-19 indicators by selected countries, as of 12/05/2020.

Country

N. of

cases †

N. of

cases

(per

100,000

pop)

N. of

tests §

N. of

tests

(per

100,000

pop)

N. of

deaths†

CFR°

(%)

Mortality

rate (per

100,000

pop)

Pop. (in

thousands)†

Cyprus 904 103.2 78,239 8,932.4 23 2.5 2.6 875.9*

Italy 219,814 363.7 2,673,655 4,424.3 30,739 14.0 50.9 60,431.3

USA 1,347,916 412.0 9,382,235 2,867.7 80,684 6.0 24.7 327,167.4

UK 223,060 335.5 2,007,146 3,018.8 32,065 14.4 48.2 66,488.9

Greece 2,726 25.4 99,363 926.2 151 5.5 1.4 10,727.7

Malta 503 104.0 44,656 9,235.4 5 1.0 1.0 483.5

Sweden 26,670 261.9 148,500 1,458.3 3,256 12.2 32.0 10,183.2

Netherlands 42,788 248.3 209,718 1,217.1 5,456 12.8 31.7 17,231

Republic of

Korea 10,936 21.2 680,890 1,318.7 258 2.4 0.5 51,635.3

†Number of cases, number of deaths and population (in thousands) for all countries, but Cyprus, as reported by ECDC at https://www.ecdc.europa.eu/en/publications-data/download-todays-data-geographic-distribution-covid-19-cases-worldwide § Data for Cyprus: internal communication; data for other countries: https://www.finddx.org/covid-19/test-tracker/ ° CFR: Case fatality ratio. * Data from Statistical Service of the Republic of Cyprus, 2018 (Statistical Service of the Republic of Cyprus)

Data are subject to change due to the rapidly evolving situation 13

Acknowledgments We thank Antry Constantinou, Christiana Soteriou, Despina Ioannou, Irene Georgiou, Maria Clerides, Tatiana Sofocleous, and Despoina Stylianou from the Ministry of Health, and the companies CELLOCK (https://cellock.com) and GEOMATIC (https://geomatic.com) for their volunteering support.

Data are subject to change due to the rapidly evolving situation 14

Appendix Table A1: Laboratory-confirmed COVID-19-cases in Cyprus by district of residence and origin (n = 904).

District/ municipality

Total Travel- related

Unknown origin

Locally-acquired

Pop. N % N % N % N %

N (per 100,000 pop)

Ammochostos 41 4.5 9 7.0 9 6.3 23 3.6 47.7 48,200

Larnaka 234 25.9 18 14.0 47 32.6 169 26.8 115.0 147,000

Aradippou 123 13.6 10 7.8 33 22.9 80 12.7 416.1 19,228

Limassol 103 11.4 28 21.7 14 9.7 61 9.7 24.9 244,900

Nicosia 350 38.7 47 36.4 48 33.3 255 40.4 74.6 341,700

Pafos 155 17.1 11 8.5 25 17.4 119 18.9 126.5 94,100

Other 21 2.3 16 12.4 1 0.7 4 0.6

Total 904 100 129 100 144 100 631 100 72.0 875,900

Other includes British Bases, abroad and unknown

Data are subject to change due to the rapidly evolving situation 15

Table A2: Sex and age distribution of asymptomatic cases at diagnosis (n = 280).

All cases (n = 904)

Asymptomatic cases (n = 280)

Characteristics N n %

Sex

Male 454 156 34.4

Female 450 124 27.6

Age groups (years)

0-9 29 11 37.9

10-19 37 16 43.2

20-29 117 42 35.9

30-39 179 66 36.9

40-49 157 46 29.3

50-59 162 42 25.9

60-69 112 21 18.8

70-79 84 29 34.5

80+ 27 7 25.9

Median age in years (IQR*) 45 (32-59) 40 (30-56) *IQR: Interquartile Range

Data are subject to change due to the rapidly evolving situation 16

Table A3: Characteristics of all deaths (n = 23).

Characteristics N %

Sex

Male 17 73.9

Female 6 26.1

Age groups (years)

0-9 0 0.0

10-19 0 0.0

20-29 0 0.0

30-39 0 0.0

40-49 1 4.3

50-59 2 8.7

60-69 6 26.1

70-79 10 43.5

80+ 4 17.4

Median age in years (IQR*) 76 (66-79) District

Ammochostos 3 13.0

Larnaka 9 39.2

Limassol 2 8.7

Nicosia 3 13.0

Pafos 6 26.1 *IQR: Interquartile Range

Data are subject to change due to the rapidly evolving situation 17

Table A4: Number of cases by date of sampling, laboratory reporting, death, and ICU admission.

Date Sampling (n = 904)

Laboratory reporting (n = 904)

Death (n = 23)

ICU admission (n = 32)

01-Mar 0 0 0 0

02-Mar 0 0 0 0

03-Mar 0 0 0 0

04-Mar 0 0 0 0

05-Mar 0 0 0 0

06-Mar 0 0 0 0

07-Mar 1 0 0 0

08-Mar 0 0 0 0

09-Mar 1 2 0 0

10-Mar 4 0 0 0

11-Mar 2 0 0 0

12-Mar 6 0 0 0

13-Mar 12 16 0 0

14-Mar 8 5 0 0

15-Mar 12 8 0 0

16-Mar 5 13 0 1

17-Mar 8 4 0 1

18-Mar 16 16 0 0

19-Mar 13 9 0 0

20-Mar 17 10 0 1

21-Mar 10 0 1 1

22-Mar 6 16 0 1

23-Mar 13 19 0 1

24-Mar 18 8 2 3

25-Mar 14 10 0 3

26-Mar 34 20 0 1

27-Mar 31 24 3 2

28-Mar 26 21 1 3

29-Mar 33 27 1 1

30-Mar 37 33 0 0

31-Mar 39 45 2 0

01-Apr 29 56 2 1

02-Apr 47 29 0 0

03-Apr 21 32 1 2

Data are subject to change due to the rapidly evolving situation 18

04-Apr 25 38 1 0

05-Apr 9 18 0 0

06-Apr 37 23 0 1

07-Apr 39 23 0 1

08-Apr 23 32 0 1

09-Apr 17 31 1 1

10-Apr 18 20 0 1

11-Apr 37 20 1 0

12-Apr 21 16 1 1

13-Apr 26 41 0 0

14-Apr 25 25 0 0

15-Apr 15 16 0 0

16-Apr 9 19 0 2

17-Apr 4 15 0 0

18-Apr 6 7 0 0

19-Apr 0 1 0 0

20-Apr 11 6 0 1

21-Apr 6 13 0 0

22-Apr 7 5 1 0

23-Apr 13 7 1 0

24-Apr 2 12 0 0

25-Apr 9 3 0 0

26-Apr 4 2 1 1

27-Apr 16 11 0 0

28-Apr 5 16 0 0

29-Apr 9 4 0 0

30-Apr 6 5 0 0

01-May 7 8 0 0

02-May 3 7 0 0

03-May 2 4 0 0

04-May 4 6 0 0

05-May 5 4 1 0

06-May 6 4 0 0

07-May 2 3 0 0

08-May 3 3 0 0

09-May 8 3 1 0

10-May 1 4 0 0

11-May 0 3 0 0

Data are subject to change due to the rapidly evolving situation 19

12-May 1 3 1 0

Data are subject to change due to the rapidly evolving situation 20

Figure A1: Distribution of cases by postal code (n = 880 with information available).

Each colour represents a different postal code and the size changes according to the number of cases.

Data are subject to change due to the rapidly evolving situation 21

Figure A2: Cumulative tests and cases per 100,000 population in Cyprus and other selected countries (Updated: 12/05/2020).

Data source for Cyprus: internal communication; data source for other countries: https://www.finddx.org/covid-19/test-tracker/ Numbers of cases, tests and deaths for Cyprus are aggregated and include people from abroad and the British bases, while the total population does not include inhabitants from abroad or from the British bases.

Data are subject to change due to the rapidly evolving situation 22

Figure A3: Time from date of sampling to death of COVID-19 cases who died (n = 23; for three cases who died on the day of sampling/reporting, the time alive has been considered 0.5 days).

Data are subject to change due to the rapidly evolving situation 23

Figure A4: Length of stay in ICU (n = 32; for two cases who died on the same day of ICU admission the length of stay in ICU has been considered 0.5 days).

Data are subject to change due to the rapidly evolving situation 24

Figure A5: Length of stay in ICU of patients who died and had been admitted to an ICU (n = 15; for two cases who died the same day of ICU admission the length of stay in ICU has been considered 0.5 days).